COVID-19 and Value-Based Reimbursement: What Do We Know? Where Will it Go?

The impacts of COVID-19 on health care continue to unfold, and one area of uncertainty is the impact COVID will have on Value Based Reimbursements (VBR). Regardless of this uncertainty it appears that VBR is still trending upwards in behavioral health care.  Surveys conducted by OPEN MINDS demonstrate more use of episodic payments, case rates, and bundled rates. In one health plan survey, the number of health plans using bundled payments or case rates rose from 39% to 59% from 2017 to 2019 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System and What Are The Health Plans Doing About VBR?). And, a more recent survey of specialty provider organizations found that 24% of those organizations have some bundled rate contracts (see 2020 OPEN MINDS Performance Management Executive Survey: Where Are We On The Road To Value). A similar trend is noted in the public payer market, where a recent state-by-state analysis found that 28 of the 40 states with Medicaid managed care require health plans to implement alternative payment arrangements (APMs) with provider organizations. This is up from 22 states out of 39 states in 2017

With the continued growth of VBR, many questions about how the pandemic will change VBR processes remain. Some current trends shed light on this question. These trends also give providers clues about areas of focus moving forward in this ‘next normal’.

Shift to Telehealth

One of the astonishing developments of the pandemic is the phenomenal growth of telehealth utilization in behavioral health care. Telehealth has become ubiquitous during the pandemic. Some interesting results of a recent survey by Qualifacts and the National Council for Behavioral Health include:

  • Pre-pandemic, telehealth utilization in behavioral health care was relatively low, only 2% of organizations were providing 80% or more of their care virtually
  • Policy changes during the COVID-19 pandemic have reduced barriers to telehealth. Now, 60% of behavioral health organizations are providing 80% or more virtual care.
  • Behavioral health care executives expect the higher utilization of virtual services to continue, with a majority believing 40 % to 60% of their overall services will be provide in virtual platforms.

In the public sector, there have been sweeping changes in regulation and reimbursement for telehealth services. While the permanence of the changes in the public payer space has not been determined, it’s evident a system-wide reevaluation is occurring.  Some states have enacted new legislation already. For instance, On July 6, 2020, the Colorado legislature passed Senate Bill 212 to expand access to Medicaid telehealth services. The bill expands Medicaid coverage for telehealth services to include reimbursement at parity with in-person services at rural health clinics, federally qualified health centers (FQHC’s), and the Indian Health Service facilities.

Furthermore, the shift to telehealth is also be reinforced by the recent recognition by the National Committee for Quality Assurance (NCQA) revision of HEDIS Quality Measures associated with Telehealth utilization during the pandemic. https://bhmpc.com/2016/10/hedis-success-value-based-care/

New NCQA HEDIS Telehealth Rules

NCQA  adjusted 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures—in response to the surge in telehealth during the pandemic (see NCQA HEDIS Quality Measures Adjusted For Increased Telehealth Use In Pandemic Crisis). The adjustments, published July 1, will go into effect in 2020 and include eight measures related to behavioral health—medication adherence, follow-up care after hospitalization or emergency department visits, and monitoring of co-occurring medical conditions in consumers with serious mental illness. For each measure, the updated guidance specifies how telehealth visits can be used and what will be included and excluded in the measure’s denominator and numerator. Most importantly, NCQA removed restrictions on video visits and now recognizes a video visit as the same as an in-person visit. Eight of the adjustments affect behavioral health measures (NCQA.org/COVID):

  1. Antidepressant Medication Management
  2. Follow-up Care for Children Prescribed ADHD Medication
  3. Follow-up After Hospitalization for Mental Illness
  4. Follow-up After Emergency Department Visit for Mental Illness
  5. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication
  6. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
  7. Diabetes Monitoring for People with Diabetes and Schizophrenia
  8. Adherence to Antipsychotic Medications for Individuals with Schizophrenia

The implication of the of the updated HEDIS measures is that telehealth coverage will carry forward to the post-crisis future. As noted by the NCQA, they cannot drive quality improvement “if their measures don’t take into account what has quickly become the fastest-growing modality for providing health care services.” For behavioral health providers who see telehealth as significant portion of outpatient services this is good news. It will also allow for more flexibility in designing programming to address VBR processes, especially when access to in person care is a major obstacle. https://www.ncqa.org/covid/

Payers are aware of the increase in utilization of telehealth and will build VBR programs around the assumption that provider are utilizing telehealth as part of their service array. Providers with fully integrated telehealth programming will be at a distinct advantage when it comes to VBR readiness in the post crisis era.

The use of telehealth is just one tool in a provider’s service array. Some COVID-19 other trends provide insight into post pandemic behavioral health utilization needs and potential cost drivers that may stimulate VBR development.

Systemic Impact of COVID-19

One interesting trend is the current underutilization of behavioral health services.  Many behavioral health providers have experienced significant decreases in utilization and revenue streams due to COVID-19, in large part due to increased unemployment from COVID-19 and the transition time of shifting benefits from private to public payer sources.

Juxtaposed against underutilization is the increase level of mental health conditions associated with the pandemic. It is expected that there will increase in levels of trauma, depression, and anxiety occurring as a result of the pandemic. The April 2020 Johns Hopkins COVID-19 Civic Life and Public Health Survey Wave 1 demonstrated a 10% increase in adults reporting serious psychological distress over 2019 reports. These results showed an exacerbation for adults with household income of less than $35,000 per year, 19% of whom reported serious psychological distress. There is also expected to be an increase in suicide rates. Unemployment is highly correlated with deaths by suicide, which has led experts to speculate that suicides will increase in 2020/2021. One model, based upon previous suicide and unemployment data, projects 3,235 to 8,164 additional deaths by suicide in the United States in 2020/20212

For payers and providers these trends will, at some point, create an increased demand for behavioral health services. Behavioral health providers with services that align to these needs, like expertise in areas of trauma informed care and crisis intervention programming, will be positioned to better serve these population health needs and meet the needs of payers who are looking for better outcomes for their consumers.

A second area of concern for all providers is the increase in opioid utilization. Due to increased opioid usage during COVID, mortality rates are expected to climb due opioid-related deaths. The American Medical Association (AMA) recently released a statement of concern about reports of increased levels of addiction and opioid-related mortality.

Value-based programs around addiction treatment have been on the rise since before COVID, both Cigna and Anthem have developed VBR programs that look at claims data in their private and public plan, tied that data consumer satisfaction surveys and outcomes. (See OPEN MINDS Addiction by the Numbers.) With the rise in opioid utilization it is reasonable to expect continued development of this treatment programming.

A Final Thought on Integrations

What is also interesting about VBR moving forward is the focus on screening, prevention, and integration of physical health care and behavioral health. Many states and national measures have incentivized screening for depression or substance abuse in primary care settings. And many plans are incentivizing referrals to co-located services and warm hand-offs where co-located services are not available. For forward-thinking behavioral health providers, the need for strong relationships with physical health care providers will present another opportunity for expanding their footprint and enhancing their revenue cycle through VBR arrangements. (See How VBR Prioritizes Primary Care as the Center of Integration.)

 

Learn more about Value Based Reimbursement with these resources from the VBCforBH.com Library.

  1. There Is No “Plan B” Alternative to Value Creating A Value-Focused Competitive Strategy in A Changing Market
  2. How to Develop Alternative Payment Models: A Guide to Building Effective Bundled Payment Models
  3. Care Delivery in A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
  4. Developing Case Rates? Better Find Your ‘Single Source of Truth’
  5. Adjust Your Strategic Sails!
  6. When the Competition Succeeds at Pay-For-Performance, What Will You Do?
  7. Options for Alternative Payment Models for Behavioral Health
  8. Using Your Performance Metrics to Build A Value Proposition for Health Plans